MEDICARE: MR. STANLEY W FITZER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	0013611	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0013611	OTHER	TX	DDS LICENSE

General Provider Information

NPI Number	:	1598794133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STANLEY W FITZER DDS

Provider Business Mailing Address
First Line	:	200 W MAGNOLIA AVE
Second Line	:	SUITE 102
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7644
Country	:	US
Telephone Number	:	817-665-1323
Fax Number	:	817-871-9074

Provider Business Practice Location Address
First Line	:	200 W MAGNOLIA AVE
Second Line	:	SUITE 102
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7644
Country	:	US
Telephone Number	:	817-665-1323
Fax Number	:	817-871-9074

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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